LEVEL 4 GENERAL NURSING UNIT

EMILIO AGUINALDO COLLEGE 1113-1117 San Marcelino St., cor. Gonzales St. Ermita, Manila School of Nursing A Case Presentation on (case title) In partial fulfillment of the requirements in (subject title) Submitted to: (Full name of C.I./area of affiliation)

Submitted by: (year & section/group#/members full name-alphabetical order)

Date Submitted

ACKNOWLEDGEMENT
We would like to thank the people who have been part of this case presentation: For the Lord Almighty who has given us strength and courage to fulfill this requirement despite our hectic schedules. for our teacher, Sir/Mam, who guided us in our clinical duties. For our families who have been very supportive in achieving our goals. For our patient who has been cooperative during our interview with him/her. For Dr. Dinah Fojas who made our topic for the case understandable at our level.

Table of Contents
(sample only) INTRODUCTION OBJECTIVES DEMOGRAPHIC PROFILE HISTORY OF PRESENT ILLNESS PATTERNS OF FUNCTIONING (PHYSICAL ASSESSMENT) ANATOMY & PHYSIOLOGY PATHOPHYSIOLOGY DRUG STUDY PARENTERAL THERAPIES DIAGNOSTIC EXAMS LABORATORY EXAMS COURSE IN THE WARDS PROBLEM IDENTIFICATION / PRIORITIZATION NURSING CARE PLAN DISCHARGE SUMMARY / PLAN REFERENCES

PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S # PAGE/S #

INTRODUCTION
(sample only)
Inguinal Hernia
Types: Who are at risk? What are the symptoms? How is it diagnosed? Herniorraphy Recovering from surgery

Preventive measures that can be done

Note: this is an overview of the entire disease condition of

the patient (summarized), written on a 1-page only

Objectives of the Study

After conducting the study, the group will be able to: Identify the factors causing. Identify the procedures on how to detect and to treat.. Identify the nursing action on how to manage (dse) as a condition of the patient Identify the pharmacologic and non-pharmacologic drugs given to the patient having the disease. Distinguish the difference of (dse) from other related diseases Advise the patient for any concerns such as health teaching and recommendation

PATIENTS DEMOGRAPHIC PROFILE

HOSPITAL #: WARD/ROOM/BED #: DATE OF ADMISSION/CONFINEMENT: TYPE OF ADMISSION: EMERGENCY NAME: ADDRESS (CITY/PROVINCE): AGE: SEX: BIRTHDATE: BIRTHPLACE: WEIGHT: RELIGION: NATIONALITY: CIVIL STATUS: OCCUPATION:

 (continuation) Chief Complaint/s: ATTENDING PHYSICIAN:

INITIAL/ADMITTING/TENTATIVE/WORKING

DIAGNOSIS: FINAL DIAGNOSIS:

HISTORY OF PRESENT ILLNESS

A. Present Illness This is a case of Mr. JTB.. who came in due to..
B. Chronological History 2 years PTA, patient noted.. 3 months PTA, after carrying a 100 kg transmission of a truck, patient noted that.

C. Past Medical History Patient has no hypertension, diabetes mellitus, and asthma. Has allergies to some foods like eggplant, sardines, and bagoong. (elaborate more) D. Family History His mother is known to be hypertensive. No known history of cardiac disease, cancer, tuberculosis, kidney problem and diabetes.(elaborate more) May use diagram & legend for visual explanation to show relatedness of the disease to the patients history.

(Continuation) E. Personal and Social History Patient is a non-smoker but occasional alcoholic drinker. He is a mechanic operator who usually carries heavy load. (elaborate more) (Note: must identify significant data related to patient condition)

(Physical Assessment Tool) GORDONS FUNCTIONAL HEALTH PATTERN GENERAL SURVEY HEALTH PERCEPTION HEALTH MNGT PATTERN NUTRITIONAL METABOLIC PATTERN ELIMINATION PATTERN ACTIVITY EXERCISE PATTERN SLEEP REST PATTERN COGNITIVE PERCEPTUAL PATTERN SELF-PERCEPTION SELF-CONCEPT PATTERN ROLE RELATIONSHIP PATTERN SEXUALITY REPRODUCTIVE PATTERN COPING STRESS TOLERANCE PATTERN VALUE- BELIEF PATTERN

PATTERNS OF FUNCTIONING

NUTRITIONAL METABOLIC PATTERN

(sample only)

SUBJECTIVE DATA: the patient stated that she only drinks 2-3 glasses/day. She also stated that she had a loss of appetite due to discomfort in swallowing of food. OBJECTIVE DATA: facial grimacing when swallowing. Swelling and redness of tonsils. Weight: 38 kg, height: 49 BMI: 19 (acceptable)

(sample only)

NORMS / STANDARDS Intake of 1200-1500 ML OR 8-10 GLASSES OF WATER/DAY for an adult BMI: <18.5 underweight 18.5 24.9 normal

25 29.9 overweight 30 39.9 obese > 40 extremely obese

General Survey
Include DATE OF ASSESSMENT
General appearance Level of consciousness Vital signs Body built Language

Sample chart for physical assessment (GORDONs) Nutritional Metabolic Pattern

BEFORE DURING HOSPITALIZATIO HOSPITALIZATIO N N NORMS/ STANDARDS (BOOK BASED/IDENTIF Y REFERENCE) ANALYSIS (DESCRIBE YOUR OWN SIGNIFICANT INTERPRETATIO N)

SUBJECTIVE CUES:

SUBJECTIVE CUES:

OBJECTIVE CUES: OBJECTIVE CUES:

ANATOMY / PHYSIOLOGY
Textbook discussion (focus on the involved body organ

and its normal function) Can add pictures (download in the internet) & references (new edition) May include Diagrams & charts

PATHOPHYSIOLOGY
PATIENT-BASED
PREDISPOSING / PRECIPITATING FACTORS MODIFIABLE & NON-MODIFIABLE FACTORS PROCESS (PATHOGENESIS) TO PRESENTING

SIGNS/SYMPTOMS TO DEVT OF COMPLICATIONS USE OF ARROWS / SYMBOLS

Pathophysiology of CVA
(sample only)
Predisposing factors

Precipitating factor

Nonmodif iable

modif iable

Process of pathogenesis/sequela Appearance of presenting signs / symptoms

DRUG STUDY
> GENERIC PATIENT DRUG > BRAND S DOSAGE CLASSIFIC NAME FREQUE ATION NCY (choose DISCON only TINUATIO applicable N to your ROUTE patient ACCEPTA condition) BLETHER APEUTIC PLASMA LEVEL SHIFTED OF DRUGS INDICATIO N >CONTRAIN DICATION (choose only applicable to your patient condition) >DRUG ACTION > (book based) >SIDEEFFECTS >ADVERSE EFFECTS >NURSING CONSIDER ATION/S (INDEPEN DENT/DEP ENDENT ACTIONS)

DRUG STUDY
Generic and brand name
Patients dosage/frequency/route/date of

discontinuation/route/therapeutic plasma level Drug classification Mechanism of action Indications / contraindications Side effects / adverse effects Nursing considerations (independent/dependent)

PARENTERAL THERAPIES
IVF (Identify the type of solution/flow rate/ amount of

solution/# of bottles consumed/drug incorporation/ identify the significance of parenteral solution to the condition of the patient) COLLOID SOLUTIONS and others Use chart format if more than 1 IVF solution is used

DIAGNOSTIC EXAM
X-RAYS / CT SCAN / MRI /ENDOSCOPY
LAPAROSCOPIC /VISUALIZATION EXAMS ECG / EEG SHOW ACTUAL / ROENTGENOLOGICAL FINDINGS INTERPRETATION / IMPRESSION OF RESULTS DATE TAKEN (PREVIOUS TO CURRENT)

LABORATORY EXAMS
URINE / FECAL / HEMATOLOGY / BACTERIOLOGY

/ BLOOD CHEMISTRY PRESENTED IN A DIAGRAM (include date taken (previous to current)/normal values/highlight actual abnormal findings/remarks/ significance of the exam & interpretation of results

Course in the Wards

Narrate pertinent significant changes on the patients

condition; new doctors order; put your nursing action (if any); new diagnostic or laboratory exams ordered; changes in medication Done at the end of your shift/daily with the patient or every RLE duty Include date/time Must be presented in a narrative/descriptive format

PROBLEM IDENTIFICATION/PRIORITIZATION
Identify all significant HEALTH PROBLEMS seen in

the patient Identify at least 3 ACTUAL and 2 POTENTIAL prioritized health problems THEN RANK IT ACCORDING TO PRIORITY JUSTIFICATION FOR EACH IDENTIFIED HEALTH PROBLEM AS TO WHY IT IS OF HIGH PRIORITY

Nursing Care Plan

Note: (Make also a Pre-op/Post-op NCP for your patient if undergone an operation) Make NCP for each HEALTH PROBLEM identified CUES/ CLUSTERED DATA /ASSESSMENT (SUBJ/OBJ) NURSING DIAGNOSIS & ETIOLOGY (1 ONLY PER CARE PLAN) INFERENCES / SCIENTIFIC ANALYSIS OBJECTIVE (S-M-A-R-T) INTERVENTIONS (Independent-Dependent-Collaborative actions) RATIONALE EVALUATION Note: present NCP in a chart form (Cues;Nsg Dx;Inference;objective;interventions;rationale;evaluation)

DISCHARGE SUMMARY / PLAN

NARRATE THE STATUS OF THE PATIENT (ACTUAL

CONTACT WITH THE PATIENT ON THE LAST DAY OF DUTY) Use M-E-T-H-O-D-S M medications E exercise T treatment H health teachings O outpatient follow-up D diet of patient S sexual / spiritual

DISCHARGE SUMMARY
Nutritional therapy Patient was advised to have regular diet, can have intake of fruits & vegetables with high fiber so as not to strain during bowel movt. Maintenance of daily activities Avoid tub baths for at least 5 days after the operation, because soaking will separate the skin tapes and the would might get infected Medical mngt Instructed patient to frequently checked for signs of infection (fever, swelling, discharges) (Note: use past tense, make instructions clear as if u were talking to the patient, avoid medical jargons)

REFERENCES
Include textbook title, edition, volume, pages,
Include all textbook & references used in during the

conduct of study May include significant websites / internet references/ addresses

Additional Information for Students

Make 3 NCP for ACTUAL health problem & 2 NCP for

POTENTIAL health problem Submit a copy of the Case Presentation to the panelist 3 days before the actual oral defense for the Grand presentation A Criteria for Grading the case presentation is given to you in advance for review of your case. Use legal size paper for your case study This is a group work, thus a group grade is given to all members of the group.